Healthcare Provider Details

I. General information

NPI: 1083169478
Provider Name (Legal Business Name): MODERN THERAPY & COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2016
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 RIBERIA ST SUITE 150
SAINT AUGUSTINE FL
32084-3300
US

IV. Provider business mailing address

4071 NEW HAMPSHIRE RD
ELKTON FL
32033-2124
US

V. Phone/Fax

Practice location:
  • Phone: 904-392-1505
  • Fax:
Mailing address:
  • Phone: 904-392-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH14185
License Number StateFL

VIII. Authorized Official

Name: MRS. JANUARY L TURNER
Title or Position: LICENSED MENTAL HEALTH COUNSELOR
Credential: MA, LMHC
Phone: 904-392-1505